Are you one of "The Trophy Generation"??

Bella mamma

I am, and I'm not impressed. And I'm not lazy thank you very much Dr. Luke.

http://www.rte.ie/radio1/podcast/podcast_patkenny.xml

PART 1, from 19 minutes
Dr. Chris Luke, ED Consultant Cork University Hospital
The discussion, from the start, is about the ED and how to have an efficient health service generally

That guy is seriously out of touch. A plane crashes in Cork and one of the A & E counsultants has time to swan around on national radio calling NCHDs lazy... and he wonders why they're having such trouble filling posts.

Ihaveanopinion

Oh Chris - Worked in this department, a doctor sees 3 or 4 patients in a shift in his A&E! I don't think so

He sees 30-40 patients per shift - I don't think so.

He is going to raise a lot of annoyed eyebrows.

Bella mamma

I couldn't see eyebrows being raised thru my radio, but I did hear hands clapping

SleepDoc

Listen.
A great number of overworked and undertrained
Nchd's are
Getting out of this country and going where they can get
Equtable treatment, training and oh maybe a bit of
Respect from consultant collgeagues who as a general rule don't get cheap laughs on national radio at our expense.

RobFowl

as a GP I felt quite insulted at his comments about GP's
To say they charge "60euro to write a bit
Of a note"
Saying Dear Dr Please
See ? abdomen
Essentially that sort of thing is nonsense. In the
Real world the vast majority of NCHD's and GP's work bloodly hard and deserve more respect and support form supposed colleagues

chanste

I am stunned that a man in his position could talk about "baby" doctors like that. I'd bet he surrounds himself with bitter old gits spending their time reminiscing of how things were better in their day!

Vorsprung

Ever since Chris Luke was reported as saying that NCHDs had "an obsession with their own work-life balance rather than serving the citizens of this country", I've taken anything he has said with a rather large pinch of salt.

Comment here - http://www.imt.ie/news/latest-news/2011/02/nchds-working-in-fools-paradise-—-imo.html

drfrank

I'm unsure as to whether this chap is simply deluded or an attention junky ?

How can any NCHD work in the ED at CUH when he is stating that you are all lazy, overpaid spoiled brats ? ? !!!!!

It is truly unbelievable. I take it he will be in the dept tomorrow apologising ? and was no doubt 'quoted out of context'

imported_guy

drfrank wrote: »

I'm unsure as to whether this chap is simply deluded or whether he is simply an attention junky ?

lol was in the gym and he was on the telly talking about the guys who died on the plane (RIP) and the ones who got injured he was the 6 o clock news (i thinkk?) those were exactly my thoughts. hes running the only level 1 trauma centre in ireland during relatively major crisis and he found the time to adress the media

opinion guy

imported_guy wrote: »

lol was in the gym and he was on the telly talking about the guys who died on the plane (RIP) and the ones who got injured he was the 6 o clock news (i thinkk?) those were exactly my thoughts. hes running the only 1 trauma centre in ireland during relatively major crisis and he found the time to adress the media

Found the time ??
He spent most of the day on the air it seems

resus

Sorry but ANYONE who works in the emergency department will attest to the absolutely inappropriate ABUSE of Emergency Medicine from SOME GPs.

YES, our OPDs are TOTALLY understaffed and that patients with chronic problems are waiting inappropriately long times for such clinics, but FFS Emergency Medicine is NOT and SHOULD NOT be a dumping ground for "acuteish" on chronic disease. We DON'T have any faster access than GPs to USS or Clinics ! Chris Luke has a very valid point there, perhaps polarised, but VERY valid.

{says me summing up all the will power to not inappropriately vent!}

RobFowl

resus wrote: »

Sorry but ANYONE who works in the emergency department will attest to the absolutely inappropriate ABUSE of Emergency Medicine from SOME GPs.

YES, our OPDs are TOTALLY understaffed and that patients with chronic problems are waiting inappropriately long times for such clinics, but FFS Emergency Medicine is NOT and SHOULD NOT be a dumping ground for "acuteish" on chronic disease. We DON'T have any faster access than GPs to USS or Clinics ! Chris Luke has a very valid point there, perhaps polarised, but VERY valid.

{says me summing up all the will power to not inappropriately vent!}

8 years working in AE and 12 as a GP and we'll agree to differ here.
Some times you have to try to understand what these "absolutely inappropriate" referrals are there for. Emergency access to USS/doagnostics is available only via AE and acute flare ups of chronic disease are absolutely appropriate referrals.
Sometimes you have to sit back and look at the best way of dealing with problems ask ask what are the reasons they have been referred. Is there an alternative pathway? Often the answer is no..

crazy dude

I have a friend who is a registrar and she took a year off work. When she returned to work she did feel that the interns tended to want you to do everything hard and wanted to observe a lot more than in her day as an intern.

SleepDoc

crazy dude wrote: »

I have a friend who is a registrar and she took a year off work. When she returned to work she did feel that the interns tended to want you to do everything hard and wanted to observe a lot more than in her day as an intern.

http://www.youtube.com/watch?v=-eDaSvRO9xA

opinion guy

crazy dude wrote: »

I have a friend who is a registrar and she took a year off work. When she returned to work she did feel that the interns tended to want you to do everything hard and wanted to observe a lot more than in her day as an intern.

Supposing this were true - is it a bad thing ?
Historically and currently interns are pushed into doing things they should not be doing without proper training. The old medical catchphrase is still very applicable - 'see one, do one, teach one'

MrCreosote

Maybe when the good Dr Luke comes up with an examination finding that rules out any serious pathology in someone with an acute abdomen, then I'll be very happy to no longer send my "?abdomen" referrals to him...

And Emergency depts don't have quicker access to imaging and bloods than GPs??? Yeah right.

ergo

what an arsehole :mad:

how dare he put this slur on the reputation of NCHD's everywhere?

I think nowadays recently graduating doctors, rather than riding on the reputations earned by doctors from back in the day, have to work harder to earn the respect from patients that was lost due to the arsehole-poor-communicator-doctor-knows-best type consultants

I could possibly speculate that the above type of doctor has likely added to ireland being one of the most litiginoos countries in the world medically speaking

at least nowadays we are training doctors that are taught basic manners and respect for patients and colleagues, more than I can say for our friend Dr. Luke (with regard to respect for colleagues anyway)

With Emergency Medicine being such an unappealing career choice for anyone who wants to stay in ireland (estimated one new ED consultant needed per year in Ireland for the forseeable future) is it any wonder sensible people are leaving for countries with actual prospects nad no glass ceiling in place?

regarding his indenture idea...well, the way I look at it is this..and for the record in my career I have worked approx 18 months in Irish ED's and 6 months in an Australian ED..
anyway, the way I see it is as follows: In Ireland I think there should be a guarantee that the NCHD's you encounter in ED should be top quality or at least competent and that the rota will be filled in whatever ED you attend. currently there are ED's that I would tell my parents/friends to avoid as the chances that you will encounter poorer quality medical staff (unsupervised) are increased

for my parents and for when I get (much) older hopefully and need to use ED's I would hope that these ED's can be staffed with the brightest (or at least competent) Irish-tax-payer funded graduates..With no career prospects in ED in Ireland there will have to be some way of putting those doctors in ED...maybe through GP and medical and surgical schemes that will be enough but possibly not with all the potential medical types leaving for foreign shores

in Australia they fill the undesirable rural positions by rotating them from the big teaching hospitals, that kind of thing may need to be increased in Ireland to help staff the ED's

but with medical SHO schemes, for example, having difficulty filling their vacancies maybe we will have to look at the options for putting interns in or something

back to original thing, once in my career did I see 30 patients in one shift, it was paeds ED though so quicker turnover, it was the shift from hell, and I was effectively unsupervised for 8 of that 12 hours.

in adult ED that kind of turnover I'm sure would bring Dr Luke lots of litiginous type headaches, does he want them seen or seen properly? Writing two words like "refer medics" might be the kind of review he wants done but that wasn't the standard practice in the Irish ED's I've worked in

resus

The interesting paradox, speaking to anyone that has worked there in the last 2 years, is that MUH (Luke's department) is probably the only ED in the country where NCHDs are guaranteed their contractual rights, have a family friendly rota, have ALL their study leave, ALL their Annual leave and are paid correctly.

ps Todays crap GP referral, on a Saturday, when we are heaving and paramedics are waiting an hour to find a trolley for their patients:
"{Usual demographics} Abdo pain since Christmas, please assess." That was ALL that was written on an A5 piece of scrap, I kid you not. Please don't try to pretend it does not happen.

tallaght01

resus wrote: »

The interesting paradox, speaking to anyone that has worked there in the last 2 years, is that MUH (Luke's department) is probably the only ED in the country where NCHDs are guaranteed their contractual rights, have a family friendly rota, have ALL their study leave, ALL their Annual leave and are paid correctly.

ps Todays crap GP referral, on a Saturday, when we are heaving and paramedics are waiting an hour to find a trolley for their patients:
"{Usual demographics} Abdo pain since Christmas, please assess." That was ALL that was written on an A5 piece of scrap, I kid you not. Please don't try to pretend it does not happen.

there's crap docs in any specialty though.

Try doing paeds, and look at the **** referrals u get from ED. Literally "presenting complaint: is a child. Plan: refer paeds".

GPs are far better than ED at making sensible referrals in paeds (in my experience).

MrCreosote

Maybe someone should start a "Hospital drs giving out about GPs" thread.

There's no point griping about bullsh*t referrals until GPs have proper access to diagnostic tests. Clinical examination is overrated anyway, and an ED doc is going to have to take a history from scratch themselves. So a letter with too much information is only going to cloud your judgement. The only things that are really important is presenting complaint, past history and medications/allergies. A big storybook history of presenting complaint?-who cares!

To go back on topic, I was interested in one thing Dr Luke mentioned which was roughly that if Drs want to get the prestige in society, they have to be ready to martyr themselves to get it. Maybe younger docs don't want to be held up as some sort of societal hero- I certainly don't. Medicine is just a job, and any doctor who feels they should have a special position for doing it is a fool.

opinion guy

MrCreosote wrote: »

To go back on topic, I was interested in one thing Dr Luke mentioned which was roughly that if Drs want to get the prestige in society, they have to be ready to martyr themselves to get it. Maybe younger docs don't want to be held up as some sort of societal hero- I certainly don't. Medicine is just a job, and any doctor who feels they should have a special position for doing it is a fool.

Indeed. And I think Dr Luke's words betray how he views himself as a doctor and a 'prestigous' member of society. He really is a gobsh1te.

Ihaveanopinion

MrCreosote wrote: »

Maybe someone should start a "Hospital drs giving out about GPs" thread.

There's no point griping about bullsh*t referrals until GPs have proper access to diagnostic tests. Clinical examination is overrated anyway, and an ED doc is going to have to take a history from scratch themselves. So a letter with too much information is only going to cloud your judgement. The only things that are really important is presenting complaint, past history and medications/allergies. A big storybook history of presenting complaint?-who cares!

I have a huge problem with this comment. Clinical exam is a hugely important part of every patient encounter. You only have to look at the US where 'clinical exam isnt that important' and you'll find that every patients gets every investigation under the sun before a doctor lays a hand on the patient. If you think that clinical exam is over-rated, you need to have a think about your approach to patients!

To go back on topic, I was interested in one thing Dr Luke mentioned which was roughly that if Drs want to get the prestige in society, they have to be ready to martyr themselves to get it. Maybe younger docs don't want to be held up as some sort of societal hero- I certainly don't. Medicine is just a job, and any doctor who feels they should have a special position for doing it is a fool.

Also not true - Medicine is a privilege - its a privilege to be able to help people and a privilege to be able to delve into peoples private lives. To compare it to 'just a job' like working in Smyths toys, or at a factory line, is a fallacy. There is prestige attached to the job whether you like it or not, so this false humility is very misplaced.

MrCreosote

Ihaveanopinion wrote: »

I have a huge problem with this comment. Clinical exam is a hugely important part of every patient encounter. You only have to look at the US where 'clinical exam isnt that important' and you'll find that every patients gets every investigation under the sun before a doctor lays a hand on the patient. If you think that clinical exam is over-rated, you need to have a think about your approach to patients!

Also not true - Medicine is a privilege - its a privilege to be able to help people and a privilege to be able to delve into peoples private lives. To compare it to 'just a job' like working in Smyths toys, or at a factory line, is a fallacy. There is prestige attached to the job whether you like it or not, so this false humility is very misplaced.

I just said it was overrated, not unnecessary! Definitely a focused clinical exam has its place but in reality it's just a performance because people expect it most of the time. It's all in the history. JAMA did a series about "rational clinical exam" a few years back which showed how bad clinical examination is in terms of sensitivity/specificity of individual examination techniques.

And I'll stand by what I said- medicine is a job. A good job generally, but a job none the less. Medicine is changing anyway- people are getting more and more of their information from the internet, and the doctor will become more of purely a technician or coordinator role. The whole doctor-patient relationship concept that has been rammed down our throats since we started university will become less important. A good thing- if you ask me, this is just a way of making the doctor feel guilty when a patient doesn't e.g. make lifestyle changes- "oh, there must be something wrong with the doctor-patient relationship."

We need to get over ourselves- I'd suggest a good start would be by banning the use of "Doctor" as a title outside the hospital. How many other professions use their job description as a title??

opinion guy

Ihaveanopinion wrote: »

I have a huge problem with this comment. Clinical exam is a hugely important part of every patient encounter. You only have to look at the US where 'clinical exam isnt that important' and you'll find that every patients gets every investigation under the sun before a doctor lays a hand on the patient. If you think that clinical exam is over-rated, you need to have a think about your approach to patients!

So whats more important then - number of tests ordered or number of diagnoses missed ? The sensitivity and specificity of almost any many clinical exam findings is broadly somewhere around 0.5 - i.e. same as chance. Your critique of the US system is only justified if the Americans were missing more diagnoses than in europe. I SERIOUSLY doubt that's true. In any case the reason people have every exam under the sun in the US (and I'd argue increasingly so in the Irish private sector) is because of the insurance companies and money.

Let me put it to you this way - if someone was giving you a history of increasing dyspnea on exertion and you were trying to determine if their heart and lungs were the issue, which would you put your faith in more - lungs clear to auscultation and normal heart sounds......or a chest x ray and an echo ????

Biologic

opinion guy wrote: »

The sensitivity and specificity of almost any clinical exam finding is broadly somewhere around 0.5 - i.e. same as chance.

I don't have an opinion on the value of clinical exams yet but your statistical comparison is disturbingly far off the mark. Chance only has a specificity of .5 if there are only 2 possibilities. Definitely not the case in medicine.

opinion guy

Biologic wrote: »

I don't have an opinion on the value of clinical exams yet but your statistical comparison is disturbingly far off the mark. Chance only has a specificity of .5 if there are only 2 possibilities. Definitely not the case in medicine.

Sigh. I don't mean to be rude but you don't know what you are talking about. Any test result can be split into one of four possiblities: true positive, false positive, true negative, false negative.

Specificity measures the percentages of true negatives correctly identified
Specificity = true negs/ (true negs + false pos)

in other words - there are one of 2 possiblities behind specificity - true neg of false pos. THerefore 0.5 is roughly equivalent of chance.

Read more here:
http://en.wikipedia.org/wiki/Sensitivity_and_specificity#Specificity


Here's an example relating to third and fourth heart sounds (actually the specifities aren't as bad as I expected, but the sensitivities are beyond crap)
http://jama.ama-assn.org/content/293/18/2238.abstract

Edit: oh and to point out - in that study the heart sound analysis was done by computer. In other words the biggest source of variation i.e. the doctor's hearing and interpretation has been eliminated. So in practical terms you might just as well be making it up

Biologic

opinion guy wrote: »

Sigh. I don't mean to be rude but you don't know what you are talking about. Any test result can be split into one of four possiblities: true positive, false positive, true negative, false negative.

Specificity measures the percentages of true negatives correctly identified
Specificity = true negs/ (true negs + false pos)

in other words - there are one of 2 possiblities behind specificity - true neg of false pos. THerefore 0.5 is roughly equivalent of chance.

Read more here:
http://en.wikipedia.org/wiki/Sensitivity_and_specificity#Specificity


Here's an example relating to third and fourth heart sounds (actually the specifities aren't as bad as I expected, but the sensitivities are beyond crap)
http://jama.ama-assn.org/content/293/18/2238.abstract

Edit: oh and to point out - in that study the heart sound analysis was done by computer. In other words the biggest source of variation i.e. the doctor's hearing and interpretation has been eliminated. So in practical terms you might just as well be making it up

No need to apologise for rudeness, I've thicker skin than that. I understand what the terms indicate. Presenting them as though there is absolutely no value in clinical examination made me think you didn't. It's a blatant false dichotomy to say that the only outcome relevant to clinical exam is the true neg/false pos rate. Examination gives essential input into forming a differential backed up with investigations. "Making it up" doesn't do this so the raw true + or - rates between chance and examination aren't comparable in isolation.
More importantly, without clinical examination you wouldn't be able to arrive at your hypothetical situation whereby you have a diagnosis to get right or wrong. It's a null point to imply that you can just make up the specificity outcome (even if it is .5) because without examination you would have nowhere to go after that even if chance brought you the right answer. I'll admit I don't know enough to get into the intricacies of clinical examination, but to compare it to chance obviously isn't applicable. That's the point I want to make.

Ihaveanopinion

Got to disagree with you again - opinion guy. There are numerous studies showing the high sensitivity and specificity of clinical examination. In fact, the common theme at the end of most of them is that expensive tests are often unnecessary. Clinical exam is more than waving a stethoscope at a chest.

A simple questionnaire to identify TIA (history taking I know - but a similar vein) Sens 82% Spec 62%

Neuroepidemiology. 2011 Feb 10;36(2):100-104. [Epub ahead of print]
Sensitivity and Specificity of Stroke Symptom Questions to Detect Stroke or Transient Ischemic Attack. Sung VW, Johnson N, Granstaff US, Jones WJ, Meschia JF, Williams LS, Safford MM.

Testing a bunch of Subscap tests - Sens 80+%

Knee Surg Sports Traumatol Arthrosc. 2010 Dec;18(12):1712-7. Epub 2010 Apr 8. Diagnostic values of clinical tests for subscapularis lesions. Bartsch M, Greiner S, Haas NP, Scheibel M.

Sens 100% Spec 80 %

Physiotherapy. 2011 Mar;97(1):59-64. Epub 2010 Aug 1.
Reliability and diagnostic validity of the slump knee bend neurodynamic test for upper/mid lumbar nerve root compression: a pilot study.
Trainor K, Pinnington MA.

Sens 86% Spec 100%

Foot Ankle Int. 2011 Feb;32(2):189-92.
Validity of the posterior tibial edema sign in posterior tibial tendon dysfunction.
Deorio JK, Shapiro SA, McNeil RB, Stansel J.

you get the idea. Anyway, my point is - to state that clinical exam is essentially a coin toss is incorrect. A proper clinical exam can obviate the need for specialised testing.

This is all a bit off point anyway. Someone who is in heart failure, of course, needs to be investigated appropriately. While I agree that Chris Luke is a gob****e, the excuse for sending people to the emergency room to beat the OPD queue is not valid.

tallaght01

Just depends on what you're looking for from the examination, and how good the "operator" is.

Some disease have very specific findings, and others don't. You can't package them up into one homogenous "clinical" examination group.

In my early neonatal days especially, I missed findings that my reg/consultant could elicit.

As far as I know Opinion guy studies/works in WIT and isn't a doctor, so don't get too stressed by what he says biologic. Those of us who've been doing it, have seen consultants diagnose some crazy **** by just clinical examination, especially the old school consultants. We've also seen people who just scan/xray everyone who walks in the door.

take everything

tallaght01 wrote: »

As far as I know Opinion guy studies/works in WIT and isn't a doctor, so don't get too stressed by what he says biologic. Those of us who've been doing it, have seen consultants diagnose some crazy **** by just clinical examination, especially the old school consultants. We've also seen people who just scan/xray everyone who walks in the door.

I wonder how many here would be confident with the different parts of the JVP. :pac:
It's unfortunate that signs aren't taught better.